The Challenge Before Us

Garrett Hardin’s “Tragedy of the Commons” is surely now upon us – we have built an unsustainable health care system.

In 1975, Howard Hiatt reflected on Hardin’s notion that “ruin is the destination toward which all men rush, each pursing his own best interest in a society that believes in the freedom of the common.”

Hiatt writes: “Surely nobody would quarrel that there is a limit to the resources any society can devote to medical care…The dilemma confronting us is how can we place additional stress on the medical commons without bringing ourselves closer to ruin.”

Are we spending more than we can afford? The recent budget fiasco that almost closed the federal government asked this question of the entire government. Particularly in health care, we spend money on lots of services that have marginal benefits with no proven effects and on care that is neither patient-centered nor efficiently given.

It is becoming more apparent that the cost of health care is a community problem that impacts the quality of education, public safety, housing, infrastructure and all other public services. So what is the role of communities in solving the problem? The federal role is significant but not sufficient.

Later this month in Madison, Wisconsin, the ABIM Foundation, the Wisconsin Collaborative for Healthcare Quality and the Center for Patient Partnerships will bring together a group of health care’s stakeholders, including leaders of hospitals and health plans, practicing physicians, patient advocate organizations, medical schools and commercial and government employers.

This meeting is intended to be the beginning of a community conversation about the best use of finite health care resources and how to create a sustainable health care system in Madison.

While our decision to host this meeting in Madison might seem random to some, it’s actually a purposeful choice. According to the Dartmouth Atlas of Health Care, Lacrosse, Wisonsin has lower expenditures per decedent in the last year of life. A community-wide campaign to increase the number of advanced directives might be part of that solution.

At the meeting, we hope to discuss what produces these types of results by answering the following:

How can we increase community-wide efforts to enhance the awareness of health care cost issues and what community-wide solutions can be found (e.g., advanced directives)

Do these results come about because of cooperation or competition?

How can we find ways to collaborate on things such as advanced directives and to compete on better health outcomes that will require better designs of health care systems?

What is the role of physician leaders and practicing physicians in these types of conversations?

What are the shared responsibilities among patients, caregivers, payers, purchasers, the medical school, the government, physicians and the delivery systems to address the sustainability of our health care system?

We will attempt to “think globally and act locally” to advance quality and affordable health care. Stay tuned for results of this important meeting.

3 Comments to “The Challenge Before Us”

Over the years, one of the most wasteful activities I have witnessed, be it outpatient or inpatient, is for a physician to recommend/order ANY test or procedure before the initial evaluation of the patient. Legitimate exceptions exist, but they are rare. I think It is wrong for an examining physician to begin a work up before laying eyes on the patient. And doing so is rarely helpful, often unnecessary, always costly, and frequently complicated with false positives.

I can certainly concur with concepts such as advanced directives since, as I understand it, 50% of the Medicare budget goes to the last year of life.
I would also advocate prospective efforts to reduce the major health epidemic for the next decades…obesity…and would suggest inexpensive approaches such as resuming physical education in schools and proponing healthy diets.

Thank you Steve, for your thoughtful comment. Reduction of obesity is a good example of a need for interventions beyond the biomedical model. We need a community-wide effort that includes farmer’s markets, bicycle/jogging paths, physical education (as you suggested), more nutritional meals in schools, and better access to weight reduction classes.